From Provincial to National: The Development of Thailand Injury Surveillance

1. From Provincial to National: The Development of Thailand Injury Surveillance Chamaiparn Santikarn, MD., MPH. Non-communicable Diseases Bureau, Ministry of Public Health Siriwan Santijiarakul, MSc. Epidemiology Bureau, Ministry of Public Health, Thailand

2. Introduction • 1995, Thailand Provincial Injury Surveillance started in 5 large sentinel hospitals • Population under surveillance - all injury cases presenting at the emergency rooms (occurred within 7 days)

3. Introduction • System objectives: Establish a database for assessing acute care and referral services; and facilitate injury prevention at provincial and national levels

4. Data flow and responsible unit E.R. Nurse Medical Record Department Medical Statistics Technicians Diskette to Epidemiology Division Report distributed within hospital and province 6 mnth. 4-6 mnth. Local action National action

5. Introduction • Emphasized on local utilization for action than centralizing the data • Local information users - physicians, nurses and policymakers • PC software specifically developed for local processing

6. Introduction • Menu of 35 ready-made tabulations • TRISS methodology was used to estimate survival probability • Screening tool to identify trauma cases with unexpected outcome for trauma audit • Quality of acute care services monitored

7. Introduction • System expanded to 22 large hospitals • In 2001, national coordinating unit proposed reducedreporting criteria, included only severe injuries (deaths, observed and /or admitted)

8. Objectives • Gain better representativeness of important injury events in each province • Better data quality • Decrease resource need 7 มีนาคม 2557 Dr. Chamaiparn Santikarn

9. Methods • To assure the sentinel hospitals Epidemiology Division used the available data • Identify workload decrease under the new criteria • Information changes due to the new criteria

10. A.D. 2001 22 reporting sentinel sites 15 study sites 7 Other sites

11. Methods • In December 2000 • Workshop for Establishing the National Injury Surveillance • Analysis results presented

12. Results With the new reporting criteria • The number of records to be reported decreased from 197,140 to 63,607 • 68 % decrease • Total workload would be decreased by 58 %

13. previous vs.. new criteria, 15 sentinel hospitals, 1998 Fig. 1 Distribution of maximum AIS of trauma cases No. of records 1 2 3 4 5 6 Max. AIS Source : 15 sentinel hospitals, provincial injury surveillance, Thailand.

14. previous vs.. new criteria, 13 non -Bangkokhospitals Fig. 2 Distribution of maximum AIS of trauma cases No. of records 1 2 3 4 5 6 Max. AIS Source : sentinel hospitals, provincial injury surveillance, Thailand 1998.

15. previous vs.. new criteria, Bangkok,1998 Fig. 3 Distribution of maximum AIS of trauma cases No. of records 1 2 3 4 5 6 Max. AIS Source : sentinel hospitals in Bangkok , provincial injury surveillance, Thailand .

16. Results • 5 leading cause of injuries in each sentinel site • Minor change 2nd - 3rd rank • Tendency towards external causes with more severe outcome

17. Five leading cause of injuries, previous criteria vs. new criteria previous criteria new criteria cases % cases % Transp. Acc 93,020 47.2 Transp. Acc 36,922 58.0 Acc. Inan. Frce 36,092 18.3 Acc. Falls * 7,987 12.6 Acc. Falls 25,597 13.0 Acc. Inan. Frce* 7,314 11.5 Assaults 16,106 8.2 Assaults 4,727 7.4 Self-harm 13,520 6.9 Self-harm 2,619 4.1 Others 12,085 6.5 Others 4,038 6.3 Total 197,140 100.0 Total 63,607 100.0

18. Results • The experts and authorities supported the new criteria • Local concerns/worries • Data for administration within the hospital • Epidemics detection of some minor injuries but potential health service burden in the provincial level

19. Results • The new criteria became minimum data collection standard for national injury surveillance • Hospitals could still use previous criteria to meet with internal need and provincial utilization

20. Results • Simple computer technique needed to manage electronic file before sending in the data

21. Results (under new criteria) • The system could continue in spite of severe manpower crisis in central coordinating unit (2002-2003) • Could report RTI victims risk behaviors monthly the Deputy Prime Minister to monitor the fight against RTI ( 2004 )

22. 2005 A.D. • 28 sentinel hospitals in network • Other 12 provincial hospitals operate this surveillance model for local use • National project to promote child MC helmet - a response to surveillance report • 14 sentinel hospitals broaden roles to health promoting hospital for road safety

23. Discussion

24. Discussions • To much workload is common for agency collecting or managing surveillance data • Negative impact on data quality and timeliness • Capacity of computer hardware usually wasted in developing countries

25. Discussions • Report of Surveillance Evaluation in Sentinel provinces (2001) • Administration within the hospital use only total number of the ER cases • Epidemics detection of minor injury not done, nor investigated

26. Discussions • Report of Surveillance Evaluation in Sentinel provinces (2001) • Severe injury data – used for monitoring referral and intra-hospital trauma care • All hospitals evaluated – still used the previous criteria !?!

27. Lesson learned • More difficult to live with less data after having it !

28. Recommendations • Future establishment of national injury surveillance system in developing countries • Focus on severe injuries only • Aims for quality of acute care as well as prevention • Sentinel surveillance work ! • Sentinel hospitals are great partnership

29. Conclusion • This reporting criteria of Thailand National injury Surveillance suitable for developing countries • resources are scarce • acute care still needs improvement • injury prevention just begun

30. Acknowledgment • International Collaborative Effort on Injury Statistics • LA Fingerhut, MA • U.S. CDC's NCHS, NIH's NICHD • 28 sentinel hospitals • Surveillance evaluating team

31. Results • Investment for the first year (not including salary) • 3.8 million baht • approximately 10,000US $ (according to the exchange rate at present )

32. Results • Distribution of trauma cases by severity • maximum AIS scale in each patient • 161,916 cases - current criteria • 47,900 cases - new criteria

33. Fig. 4 Distribution of age of trauma cases current vs. new criteria, 15 sentinel hospitals, 1998 No. of records Age [year] <1 5-9 15-19 25-29 35-39 45-49 55-59

34. Fig. 5 Distribution of age of trauma cases compared between current v.s. new criteria, 15 sentinel hospitals, 1998 Percentage 5-9 25-29 45-49 >1 15-19 35-39 55-59 % of decreased of new criteria cases Age [year]

35. ResultsData quality A.D. 2001 New national report criteria • Report coverage • Observed & admitted 86% • Dead cases 77% • Completeness and reliability 89% • Timeliness in data entering within 30 days 46%